Section 10. Liver and Gallbladder Disorders

Chapter 137. Hepatitis

Topics: Introduction | Acute Viral Hepatitis | Chronic Hepatitis

Chronic Hepatitis

Chronic hepatitis is inflammation of the liver that lasts at least 6 months.

Chronic hepatitis, though much less common than acute hepatitis, can persist for years, even decades. In most people, it is quite mild and does not cause significant liver damage. In some people, though, continued inflammation slowly damages the liver, eventually producing cirrhosis (severe scarring of the liver), liver failure, and sometimes liver cancer.

Causes

About one third of people with chronic hepatitis develop it after a bout of acute viral hepatitis. The remaining two thirds of people develop the disease gradually without any obvious symptoms, although most cases of chronic hepatitis are still caused by one of the hepatitis viruses.

Hepatitis C virus is the most common cause of chronic hepatitis; at least 75% of acute hepatitis C cases become chronic. Hepatitis B virus, sometimes together with hepatitis D virus, causes a smaller percentage of chronic infections. Hepatitis A and E viruses do not cause chronic hepatitis.

Drugs such as methyldopa, isoniazid, nitrofurantoin, and possibly acetaminophen can cause chronic hepatitis, particularly when they are taken for prolonged periods. Wilson's disease, a rare hereditary disease involving abnormal retention of copper in the liver (see Section 12, Chapter 155), may cause chronic hepatitis in children and young adults.

No one knows exactly why a particular virus or drug causes chronic hepatitis in some people but not in others, or why the degree of severity varies. In many people with chronic hepatitis, no obvious cause can be found. In some of these people, there appears to be an overactive immune system response that is responsible for the chronic inflammation. This response may occur because the body is attacking its own tissues (an autoimmune reaction (see Section 16, Chapter 186)), although this has not been proven. This disease, called autoimmune hepatitis, is more common among women than men.

Symptoms and Diagnosis

Many people with chronic hepatitis have no symptoms at all. For those who do, the symptoms often include a feeling of illness, poor appetite, and fatigue. Sometimes an affected person also has a low-grade fever and some upper abdominal discomfort. Jaundice may or may not develop. Features of chronic liver disease may eventually develop. These can include an enlarged spleen, spiderlike blood vessels in the skin, and fluid retention. Other features may occur, especially in young women with autoimmune hepatitis. Such features can involve virtually any body system and include acne, cessation of menstrual periods, joint pain, lung scarring, inflammation of the thyroid gland and kidneys, and anemia.

Many people have chronic hepatitis for years without developing progressive liver damage. For others, the disease gradually worsens. Over a period of years, about 20% of people with chronic hepatitis C and about 50% of people with autoimmune hepatitis develop cirrhosis, with or without liver failure.

Although the person's symptoms and liver function test results provide helpful diagnostic information, a liver biopsy (see Section 10, Chapter 134) is essential for a definite diagnosis. The liver biopsy allows a doctor to determine the severity of the inflammation and whether any scarring or cirrhosis has developed. The biopsy may also reveal the underlying cause of the hepatitis. Occasionally, a biopsy needs to be performed more than once.

Treatment

In people with progressive chronic hepatitis C infection, a combination of the antiviral agent interferon-alpha plus ribavirin is most commonly used. This combination may stop the inflammation. However, hepatitis tends to recur once treatment is stopped, and the overall success rate is only about 30 to 40%. Side effects are common. In people with chronic hepatitis B, treatment with interferon-alpha or lamivudine is sometimes effective.

If use of a particular drug is suspected of causing the hepatitis, then discontinuing the drug may effectively treat the disease.

Autoimmune hepatitis is usually treated with corticosteroids, sometimes in combination with azathioprine. These drugs suppress the inflammation, resolve the symptoms, and improve long-term survival. Nevertheless, scarring in the liver may gradually worsen. Discontinuing therapy usually leads to a recurrence of the inflammation, so most people have to take the drugs indefinitely.

Regardless of the cause or type of chronic hepatitis, any complications--such as fluid in the abdominal cavity (ascites (see Section 10, Chapter 135)) or abnormal brain function (liver encephalopathy (see Section 10, Chapter 135))--require treatment.

Liver transplantation (see Section 16, Chapter 187) may be considered for a person with severe liver failure. However, liver transplantation is not generally suitable for a person with hepatitis B infection, because recurrence of the infection tends to occur early and severely in the transplanted liver. For people with hepatitis C, the infection virtually always recurs in the transplanted liver, but the disease is usually so mild that the person is likely to survive for many years.